Coders Urged to Avoid Clinical Coding Risks

I’m often asked about how one would or should strive for coding compliance and make it happen. The first thing I do is to identify and acknowledge the risks or potential risks that occur. We all know that there are risks across healthcare, and some specific ones within health information management (HIM) and coding. The April 2017 report from Crowe Horwath titled, “20 of the Top Risk Areas in Healthcare”[i] included these risk areas related to clinical coding:

Clinical Documentation Improvement (CDI)

Billing and collections

Inpatient coding

Charge capture

Physician practice coding and billing

In addition to the above risks, I often watch and then review the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reports relating to healthcare, as they do provide some very important findings and warnings to take heed of. Then there is your own external and internal auditing of documentation and coding which will help to identify risks.

As a foundation to your coding compliance plan you’ll want to review the OIG seven key compliance elements[ii] as these provide a set of crucial components that can be included into your program:

Standards of Conduct

Compliance Officer and Board/Committee

Education

Auditing and Monitoring

Reporting and Investigations

Enforcement and Discipline

Response and Prevention

An additional resource to utilize for your coding compliance program is the American Health Information Management Association (AHIMA) Code of Ethics[iii] for HIM, which includes the following seven elements:

Establishes a set of ethical principles to be used to guide decision-making and actions.

Establishes a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise.

Provides ethical principles by which the general public can hold the HIM professional accountable.

Mentors practitioners new to the field to HIM's mission, values, and ethical principles.

I like to see an organization, company, or practice establish a code of ethics or embrace and acknowledge the AHIMA code as one they follow and adhere to.

To dive deeper into coding compliance, you should also make use of the AHIMA Standards of Ethical Coding iv. This industry gold standard contains eleven (11) principles that make up the basis of the ethical coding:

Gather and report all data required for internal and external reporting, in accordance with applicable requirements and data set definitions.

Assign and report, in any format, only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions and requirements.

Query and/or consult, as needed, with the provider for clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices.

Refuse to participate in, support, or change reported data and/or narrative titles, billing data, clinical documentation practices, or any coding-related activities intended to skew or misrepresent data and their meaning that do not comply with requirements.

Facilitate, advocate, and collaborate with healthcare professionals in the pursuit of accurate, complete and reliable coded data and in situations that support ethical coding practices.

Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements.

Maintain the confidentiality of protected health information in accordance with the Code of Ethics.

Refuse to participate in the development of coding and coding-related technology that is not designed in accordance with requirements.

Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

When building your coding compliance program you’ll also want to have written policies and procedures (P&P) in place. These are not simply a verbal direction, but written and detailed. This is one area I’ve seen and heard over the years that is often missing from a coding compliance program. I also have heard how a P&P for coding is contrary to the Official Guidelines, which would not be appropriate (often there is a financial incentive behind this type of P&P). Some basic P&Ps would include, but are not limited to these examples:

Required resources for coding

Official Guidelines for Coding and Reporting ICD-10-CM/PCS

AHA Coding Clinic

AMA CPT® codebook

AMA CPT® Assistant

Education and Training

Required education and training for the specific coding position

Ongoing CEU requirements and maintenance

Education and Training of external and vendor coding staff

Physician Querying

Auditing and Monitoring

Correction and Rebilling

Your P&Ps should be reviewed at least every two years to make adjustments, etc., but more often as needed, such as a regulatory change. More can be said about P&Ps but for the context of this article, the above would be a good place for you to start.

When you have your program in place and operational, you’ll want to assess the overall coding compliance program effectiveness at least every two years (more often if needed) to ensure success and the desired outcomes are being achieved. This assessment may be done by an external resource and would include interviews with staff as well. The coding compliance leadership should be open and engaging, plus have transparency, as this will greatly help your effectiveness and success.

You don’t want to wait for regulators to knock on your door, so ensure you have a strong and achievable coding compliance program that is working. Keep in mind that it’s always best to be proactive rather than reactive when it comes to compliance. I hope you’ll discuss your coding compliance efforts, or lack thereof, now, and not wait for a risk to impact your organization or practice.

Ultimately your coding compliance program/plan will assist with achieving accuracy and integrity with clinical documentation and coding. Making all this happen however, will take time and effort, leadership, dedication, and accountability. I strongly encourage all settings of healthcare to work on and achieve coding compliance that really works!

Program Note

Be sure to listen to Gloryanne Bryant today on Talk Ten Tuesdays at 10 a.m. ET.

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICd-10-CM/PCS Trainer, is a 40-year HIM coding professional, focusing on compliance and ethics. She is a member of the ICD10monitor editorial board, and a popular panelist on Talk Ten Tuesdays.

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